Sean Huntroyd

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Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr Sean Huntroyd,
a prisoner at HMP Winchester,
on 7 May 2020
A report by the Prisons and Probation Ombudsman
Third Floor, 10 South Colonnade Email: mail@ppo.gov.uk T l 020 7633 4100
Canary Wharf, London E14 4PU Web: www.ppo.gov.uk
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© Crown copyright, 2024
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The Prisons and Probation Ombudsman aims to make a significant contribution to safer,
fairer custody and community supervision. One of the most important ways in which we
work towards that aim is by carrying out independent investigations into deaths, due to any
cause, of prisoners, young people in detention, residents of approved premises and
detainees in immigration centres.
If my office is to best assist His Majesty’s Prison and Probation Service (HMPPS) in
ensuring the standard of care received by those within service remit is appropriate, our
recommendations should be focused, evidenced and viable. This is especially the case if
there is evidence of systemic failure.
Mr Sean Huntroyd died of internal bleeding caused by ruptured veins in his abdomen on 7
May 2020, while a prisoner at HMP Winchester. He was 46 years old. We offer our
condolences to Mr Huntroyd’s family and friends.
Mr Huntroyd had a number of significant chronic health conditions, including cirrhosis of
the liver and type 2 diabetes. He also had a long history of illicit drug use and alcohol
abuse.
The clinical reviewer concluded that the clinical care that Mr Huntroyd received at
Winchester was good and equivalent to that which he could have expected to receive in
the community.
I am concerned that it was left to another prisoner, Mr Huntroyd’s son, to collect medical
equipment during the emergency response. This was inappropriate and caused a slight
delay while Mr Huntroyd was receiving emergency treatment – although I am satisfied that
this did not contribute to his death.
I have also made recommendations about family liaison and accessing medical
equipment.
This version of my report, published on my website, has been amended to remove the
names of staff and prisoners involved in my investigation.
Sue McAllister
Prisons and Probation Ombudsman 1 April 2022
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 3
Background Information ................................................................................................... 4
Key Events ....................................................................................................................... 6
Findings ......................................................................................................................... 10
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Summary
Events
1. On 29 January 2020, Mr Sean Huntroyd was remanded to HMP Winchester for
shoplifting and breach of a community order. This was not his first time in prison.
2. Mr Huntroyd had type 2 diabetes and cirrhosis of the liver. He also had a significant
history of illicit drug and alcohol misuse. He was seen regularly by the Integrated
Substance Misuse Services (ISMS). He completed an alcohol detox but remained
on a methadone programme throughout his time at Winchester.
3. On 18 March, Mr Huntroyd was taken to hospital by emergency ambulance after he
felt unwell and collapsed. Hospital doctors found that he had had an intra-
abdominal/variceal bleed (bleeding from swollen veins in the abdomen, a
recognised complication of advanced liver cirrhosis). He remained in hospital until
23 March, when he was discharged back to Winchester with medication to manage
his conditions.
4. Just after 4.00pm on 7 May, an officer called for a member of healthcare to check
on Mr Huntroyd after he said he felt ’funny’. The officer thought that Mr Huntroyd
was under the influence of drugs and Mr Huntroyd confirmed that he had smoked
’spice’, an illicit psychoactive substance.
5. A prison paramedic arrived at the cell. She was unable to get a blood pressure
reading using the manual blood pressure (BP) cuff, which meant that his blood
pressure was low. She asked one of the officers to collect another BP machine
from the treatment room on the wing. Mr Huntroyd’s son (who lived in the cell next
door to his father’s) ran to the treatment room to collect the medical equipment but
when he arrived, he was told that he could not have it. He returned to the cell and
one of the officers ran and collected it instead.
6. At 4.21pm, officers radioed a code blue medical emergency (indicating a life-
threatening situation) and an ambulance was called immediately. Mr Huntroyd’s
condition deteriorated very quickly. Additional nursing staff arrived and attempted
to give Mr Huntroyd oxygen, but he resisted as he was quite agitated.
7. The ambulance crew arrived at Mr Huntroyd’s cell at 4.32pm. As they began to
treat him, he stopped breathing and no pulse could be detected. They began CPR
and took Mr Huntroyd to hospital by emergency ambulance.
8. Mr Huntroyd’s condition continued to deteriorate and at 5.37pm, it was confirmed
that he had died.
9. The post-mortem found that he had suffered a catastrophic internal bleed caused
by cirrhosis of the liver.
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Findings
10. The clinical reviewer concluded that the care Mr Huntroyd received at Winchester
was equivalent to that which he could have expected to receive in the community.
11. We are concerned that both medical and prison staff allowed Mr Huntroyd’s son
(also a prisoner at Winchester) to collect medical equipment during the emergency
response. This led to a slight delay in obtaining the equipment. Although this did
not impact on the treatment or outcome for Mr Huntroyd, it could be critical in future
medical emergencies.
12. Although the prison told us that they had appointed two family liaison officers, they
were unable to provide us with a copy of the Family Liaison Officer Log, as they
should have done. As a result, the investigation was not initially able to establish
what steps the FLOs took to notify Mr Huntroyd’s nominated next of kin of his death.
However, following issue of our initial report the prison provided handwritten notes
completed at the time, which detailed the process.
13. There was also initially no evidence provided that a staff de-brief had taken place
following Mr Huntroyd’s death on 7 May or that staff were offered support. The
prison has since provided handwritten notes that detail this process although the
process was not minuted. The investigation has learnt since issuing of our initial
report that the requirement for minutes of such de-briefs to be recorded is no longer
valid, and therefore a previous recommendation has been removed. The notes also
indicated that staff support was offered.
Recommendations
• The Governor and Head of Healthcare should all remind staff that it is not
appropriate to request or expect prisoners to collect medical equipment in medical
emergencies.
• The Governor should ensure that all decisions taken are recorded in the Family
Liaison Officer’s log.
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The Investigation Process
14. The investigator issued notices to staff and prisoners at HMP Winchester informing
them of the investigation and asking anyone with relevant information to contact
her. No one responded.
15. The investigator obtained copies of relevant extracts from Mr Huntroyd’s prison and
medical records. She interviewed six members of staff at Winchester in July 2020
and received written statements from four members of staff and one from Mr
Huntroyd’s son. All of the interviews were conducted by telephone due to revised
working practices during the COVID-19 pandemic. The investigation was
subsequently reallocated to one of Ms Boddy’s colleagues, to produce the
investigation report.
16. NHS England commissioned a clinical reviewer to review Mr Huntroyd’s clinical
care at the prison. The clinical reviewer jointly interviewed two healthcare staff with
the original investigator.
17. We informed HM Coroner for Hampshire Central of the investigation. Our
investigation was suspended while we waited for the cause of death. The coroner
gave us the post-mortem report. We have sent the coroner a copy of this report.
18. One of the Ombudsman’s family liaison officers contacted Mr Huntroyd’s nominated
next of kin to explain the investigation and to ask if they had any matters, they
wanted the investigation to consider. They did not respond to our letter.
19. An inquest was concluded on 29 November 2023 and found Mr Huntroyd’s death
was the result of natural causes.
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Background Information
HMP Winchester
20. HMP Winchester is a local prison serving courts in Winchester, Southampton,
Portsmouth, Bournemouth, Salisbury, Aldershot and Basingstoke. It holds around
700 adult remanded and sentenced men. It includes a separate Category C unit for
up to 129 sentenced men nearing the end of their sentence. At the time of Mr
Huntroyd’s death, Central and Northwest London NHS Foundation Trust provided
healthcare at the prison and 24-hour healthcare cover.
HM Inspectorate of Prisons
21. The most recent inspection of HMP Winchester was conducted in June and July
2019. Inspectors concluded that the inspection overall was “disappointing”.
However, Inspectors noted that senior managers had been appointed relatively
recently and were supported by a team of managers who were as optimistic and
committed. Inspectors also noted that the Governor and his team had articulated a
clear vision for the future of the establishment and seemed to be working to a plan
that appeared to have arrested decline and gave some evidence of early
improvement.
22. Inspectors found that the range of health provision was appropriate, and prisoners
had good access to most clinics, although the management of long-term conditions
needed better coordination. Substance use support was good, and a wide range of
psychological interventions and patient-centred clinical treatment was available.
23. In June 2020, HMIP conducted a short scrutiny visit at Winchester to look at key
issues during the COVID-19 pandemic. They found that healthcare provision was
good. Mental health support remined proactive and support to overcome substance
misuse problems continued, although in a curtailed form.
Independent Monitoring Board
24. Each prison has an Independent Monitoring Board (IMB) of unpaid volunteers from
the local community who help to ensure that prisoners are treated fairly and
decently. In its latest annual report, for the year to May 2021, the IMB reported that
Winchester was to be commended for its response to COVID-19 and its success in
preventing internally generated infection. Winchester was one of the last of all the
local prisons to be designated as an ‘outbreak’ site (in January 2021) it controlled
and reduced the incidents as well as could be expected.
Previous deaths at HMP Winchester
25. Mr Huntroyd was the tenth prisoner to die at Winchester since May 2018. Of the
previous deaths, five were from natural causes and four were self-inflicted. There
have been seven deaths at Winchester since Mr Huntroyd’s death. Five were from
natural causes and two were self-inflicted deaths.
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26. In a previous investigation into a death at Winchester in March 2019, we were
concerned about the prison’s emergency response procedures. We recommended
that the Governor should remind staff of the importance of using the correct medical
emergency codes in an emergency and the potential consequences of not doing so.
The prison accepted our recommendation and said that the Governor had re-issued
a notice to staff in January 2020, to remind staff of the importance of using the
correct emergency codes immediately, in line with PSI 03/2013, which also outlined
the potential consequences of any delays in calling the appropriate emergency
code.
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Key Events
27. On 29 January 2020, Mr Sean Huntroyd was remanded to HMP Winchester for
shoplifting and breach of a community order. He had been in prison before.
28. During his initial health screen, Mr Huntroyd said that he was currently on
medication for type 2 diabetes. It was also recorded that he had a significant
history of illicit drug and alcohol misuse. The nurse referred him to the prison’s
substance misuse team. Mr Huntroyd said that he had previously self-harmed but
currently had no thoughts or intentions of suicide or self-harm.
29. Later the same day, a nurse completed an initial drug and alcohol assessment with
him. She recorded that he had been in police custody for one day, during which
time he had been given diazepam for alcohol withdrawal and dihydrocodeine for
opiate withdrawal. Mr Huntroyd told the nurse that he smoked and injected heroin
and also used ‘crack’ cocaine and illicit methadone in the community and had been
drinking a bottle of vodka and two bottles of wine and cider a day before his arrest.
Mr Huntroyd said that he had last used drugs the day before arriving at Winchester.
30. The nurse noted that Mr Huntroyd was displaying mild symptoms of both opiate and
alcohol withdrawal and planned to administer 10mls of methadone on the first night
in custody, increasing to 20mls daily for 3 days, pending a review. Mr Huntroyd
was also prescribed alcohol detoxification medication. It was planned that he would
be located in a cell with an observation hatch rather than a panel, so that his
withdrawal could be closely monitored.
31. On 5 February, Mr Huntroyd was moved from C wing to D wing at his own request
because his son was located there. They began sharing a cell.
32. On 8 February, a prison GP recorded that Mr Huntroyd had a history of pancreatitis
(inflamed liver) and liver cirrhosis (scarring of the liver) as a result of alcohol
dependency. She also recorded that in 2019, he had had an episode of
haematemesis (vomiting blood) and melaena (blood in the stools), both symptoms
of an upper gastrointestinal bleed (a recognised complication of cirrhosis).
Following examination, she recorded a possible diagnosis of an enlarged liver. She
requested blood tests and asked healthcare staff to obtain the results of a
colonoscopy Mr Huntroyd had had in the community.
33. Mr Huntroyd continued to be monitored regularly and managed by the Integrated
Substance Misuse Services (ISMS). He completed his alcohol detox but remained
on a methadone programme throughout his time at Winchester. The healthcare
team also reviewed Mr Huntroyd regularly in order to monitor his long-term
conditions.
Events of March 2020
34. On 17 and 18 March, Mr Huntroyd attended sessions run by Phoenix Futures, a
charitable organisation helping prisoners with drug and alcohol addiction. However,
on 18 March, Mr Huntroyd complained of feeling unwell and had to leave the
session early. Once outside the classroom, he collapsed. Staff radioed a code
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blue (indicating a prisoner is unconscious or having breathing difficulties) and an
ambulance was called immediately.
35. Two prison paramedics and the prison GP went to his cell in response to the code
blue. The prison GP recorded that Mr Huntroyd was cold, clammy and pale and
had low blood pressure. She suspected that he had had an abdominal aortic
aneurysm perforation (internal bleed) which had caused his collapse. Mr Huntroyd
was taken to hospital by emergency ambulance.
36. Mr Huntroyd was admitted to hospital as an inpatient and investigations were
undertaken to determine the cause of his collapse. The hospital said that Mr
Huntroyd was “not a well man”. The prison notified Mr Huntroyd’s son who was
given access to a telephone to notify other family members.
37. While in hospital Mr Huntroyd tested negative for COVID-19.
38. On 23 March, Mr Huntroyd was discharged from hospital and returned to
Winchester. His discharge notes recorded that his collapse was due to an intra-
abdominal/variceal bleed (a bleed from swollen veins in the abdomen) and that he
had marked cirrhosis of the liver, liver varices (enlarged or swollen veins,) portal
hypertension (increased pressure in the vein carrying blood from the digestive
organs to the liver) and calcification of his aorta. He was prescribed appropriate
medication to manage his conditions and was to be seen regularly for review.
39. On his return to Winchester, Mr Huntroyd was taken back to D wing where he was
allocated a single cell as a precautionary measure against COVID-19. (His son
lived in the cell next door.) His health was closely monitored.
40. On 29 March, the prison GP recorded that although test results had indicated that
Mr Huntroyd’s liver function had improved, his platelets were low. (Platelets help
form blood clots and stop or prevent bleeding and a low platelet count can lead to
internal bleeding.) The prison GP recorded that she planned to discuss this with the
hospital haematology team.
7 May 2020
41. Just after 4.00pm on 7 May, an officer went to Mr Huntroyd’s cell to ask if he was
ready to collect his medication. The officer said that Mr Huntroyd was standing in
his cell making a cup of tea and raised no concerns. The officer said that he had no
concerns about Mr Huntroyd’s appearance. The officer said that he then went
further along the landing to speak to another prisoner. While he was doing so, Mr
Huntroyd shouted out to the other prisoner. The prisoner went to Mr Huntroyd’s cell
and then returned and said to the officer, ‘You might want to go and see if Sean is
ok.’
42. The officer said that he went back to Mr Huntroyd’s cell and found Mr Huntroyd
leaning against the wall. Mr Huntroyd said that he felt ‘funny’. The officer said that
Mr Huntroyd, ‘did not look quite right’ and that he therefore radioed for a member of
the nursing team to come and check on Mr Huntroyd. The officer said that he did
not call a medical emergency code because he initially thought that Mr Huntroyd
was under the influence of ‘spice’, an illicit psychoactive substance.
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43. At around the same time, another officer was walking along the landing with Mr
Huntroyd’s son when a second prisoner told them they should go to Mr Huntroyd’s
cell. The second officer said that there was no urgency in the prisoner’s voice. The
second officer went to the cell and Mr Huntroyd’s son followed him. When they
arrived, they saw that the first officer was trying to encourage Mr Huntroyd to lie on
his bed and calm down. He said that they asked Mr Huntroyd whether he had
taken any illicit substance. Initially, Mr Huntroyd did not answer but then said, ‘Yes,
spice.’
44. In a written statement Mr Huntroyd’s son also said his father had told the officers he
had taken ‘spice’, although he said that he told them he did not think ‘spice’ was the
problem and that his father’s symptoms were the same as when he had collapsed a
few weeks earlier.
45. A prison paramedic arrived at the cell at 4.07pm. She said that she only took a
small emergency bag with her as she knew that Mr Huntroyd was conscious and
breathing. When she arrived at the cell, the officers told her that Mr Huntroyd had
said that he had used ‘spice.’ Mr Huntroyd’s son said in his statement that he told
her he thought his father was having a repeat of his symptoms a few weeks earlier.
46. The prison paramedic said that Mr Huntroyd was sitting on the edge of his bed. He
was very pale, and his skin was cold to the touch. He had a low temperature and
said he could not breathe. She attempted to feel for a pulse but was unable to
detect one, so she knew that his blood pressure was low. She was unable to get a
blood pressure reading using the manual blood pressure (BP) cuff. She asked one
of the officers to collect another BP machine (which was not in the emergency bag)
from the treatment room on the wing. Mr Huntroyd’s son ran to collect the medical
equipment. Healthcare staff told him that that he could not have it so he returned to
the cell and one of the officers ran and collected it instead.
47. The prison paramedic asked the officers to radio a code blue because she
considered that Mr Huntroyd needed to go to hospital. The code blue call was
recorded at 4.21pm. An ambulance was called immediately.
48. The prison paramedic said that Mr Huntroyd’s condition deteriorated very quickly.
Additional nursing staff arrived and attempted to give Mr Huntroyd oxygen, but he
resisted and was quite agitated. The ambulance arrived at the prison at 4.27pm
and ambulance staff were with Mr Huntroyd at 4.32pm. The officer told them what
Mr Huntroyd’s son had said about his previous collapse.
49. When the ambulance crew arrived at the cell, Mr Huntroyd was still responsive but,
as they began to treat him, he stopped breathing and no pulse could be detected.
He was immediately moved onto the floor and a defibrillator was attached to his
chest. The ambulance crew started chest compressions and a second ambulance
crew arrived. Mr Huntroyd was transferred to the waiting ambulance was taken to
hospital.
50. Mr Huntroyd’s condition continued to deteriorate in hospital and at 5.37pm, it was
confirmed that Mr Huntroyd had died.
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Contact with Mr Huntroyd’s family.
51. Following Mr Huntroyd’s death, the prison appointed two officers as Family Liaison
Officers (FLOs). The investigation was unable to initially establish what steps the
FLOs took to inform the next of kin of Mr Huntroyd’s death as no FLO Log was
provided.
Support for prisoners and staff
52. There is evidence to indicate that the prison conducted a debrief and that prison
and healthcare staff were offered support.
53. The prison posted notices informing other prisoners of Mr Huntroyd’s death and
offering support. Staff reviewed all prisoners assessed as being at risk of suicide or
self-harm in case they had been adversely affected by Mr Huntroyd’s death.
Post-mortem report
54. The pathologist gave Mr Huntroyd’s cause of death as haemoperitoneum (bleeding
in the abdominal cavity) caused by a ruptured peritoneal varix (ruptured veins in the
abdominal cavity as a result of portal hypertension), which was in turn caused by
cirrhosis of the liver.
55. The pathologist said that he considered that the origin of the bleeding was likely to
have been similar to that when Mr Huntroyd had collapsed in March 2020, but that
on this occasion the bleeding was catastrophic and resulted in massive blood loss
leading to sudden death.
56. The pathologist said that some drugs may increase blood pressure and so increase
the risk of intraperitoneal haemorrhage. However, no toxicology tests could be
carried out to determine whether Mr Huntroyd had taken any illicit substances as
the samples of urine and blood taken during the post-mortem had been disposed of
by the police without being analysed.
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Findings
Clinical care
57. The clinical reviewer concluded that the clinical care that Mr Huntroyd received at
Winchester was good and equivalent to that which he could have expected to
receive in the community.
58. She found that the prison GP and the prison’s healthcare team reviewed Mr
Huntroyd at regular intervals, and that this included reviews of his medication and
blood test results and implementation of the recommendations made by hospital
doctors following Mr Huntroyd’s discharge from hospital on 23 March 2020. She
also found that the ISMS team met regularly with Mr Huntroyd and provided
ongoing support to him during his time at Winchester.
59. The clinical reviewer did, however, identify a number of concerns relating to general
healthcare provision. We do not repeat her recommendations in this report as the
issues she raises did not directly impact on Mr Huntroyd’s death, but the Head of
Healthcare will need to address them.
Emergency response
60. When the prison paramedic was unable to obtain a BP reading using the manual
BP cuff, she asked that an automated BP machine be collected from the treatment
room. At this point it appears that Mr Huntroyd’s son was either sent for it or took it
upon himself to go and collect the machine. However, because he was a prisoner,
healthcare staff refused to give it to him, so a member of staff was sent to collect it.
61. Staff should not have relied on Mr Huntroyd’s son to collect the equipment. While
the slight delay in obtaining the equipment did not impact on the treatment or
outcome for Mr Huntroyd, it could be critical in other circumstances. We make the
following recommendation:
The Governor should remind staff that it is not appropriate to request or
expect prisoners to collect medical equipment in medical emergencies.
Family liaison
62. Prison Service Instruction (PSI) 64/2011 on safer custody says that following a
death in custody, the next of kin must be contacted by an appropriate person. The
next of kin must be given an accurate account of what has happened and what will
happen next, and an offer must be made to contribute to funeral expenses.
63. The prison told us that they had appointed two family liaison officers, but they did
not provide a copy of the Family Liaison Officer Log as they should have done. As
a result, the investigation has not been able to establish what steps the FLOs took
to notify the next of kin of Mr Huntroyd’s death. Following publication of the initial
report, the prison provided handwritten notes that indicated that the officer had
taken steps to contact and notify the next of kin as listed by Mr Huntroyd. The
notes only detail that initial attempts to make contact were unsuccessful and that
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other means of contact were sought. Mr Huntroyd’s son was also informed about
his father’s death and supported via the chaplaincy team. We recommend:
The Governor should ensure that all decisions taken are recorded in the
Family Liaison Officer’s log.
64. The prison paid toward the cost of Mr Huntroyd’s funeral in line with national policy.
National policy states that a contribution of up to £3000 toward ‘reasonable’ costs
should be made.
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